Healthcare Provider Details

I. General information

NPI: 1649725938
Provider Name (Legal Business Name): TIA JACKSON MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIA JANDRIN

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

IV. Provider business mailing address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

V. Phone/Fax

Practice location:
  • Phone: 920-746-0410
  • Fax:
Mailing address:
  • Phone: 920-746-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1559-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: